Vaccine Financing, the Affordable Care Act (ACA), and Immunizations

26 Pages·2015·0.58 MB·English

by  Julie Murphy

Vaccine Financing, the
Affordable Care Act (ACA),
and Immunizations
May 12th, 2015
Litjen (L.J) Tan, MS, PhD
Chief Strategy Officer, Immunization Action
Coalition
Disclosures
• I have received honoraria from Pfizer, Novartis,
Temptime Corp., TruMedSystems, and Sanofi
Pasteur for service as a scientific consultant.
– My honoraria is donated to the IAC
• I do NOT intend to discuss an unapproved or
investigative use of a commercial
product/device in my presentation.
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Disclaimer
The opinions expressed in this presentation are solely
those of the presenter and do not necessarily
represent the official positions of the Immunization
Action Coalition, or the National Adult and Influenza
Immunization Summit
Objectives
• Vaccine Financing in the United States
• The Affordable Care Act (ACA)
– ACA impact on immunizations
– What are the challenges for immunization efforts in
the era of the ACA
• Challenges Facing Providers of Adult
immunizations
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Vaccine Financing in the
United States
Vaccine Financing in the United States
• Vaccines For Children (VFC, ~45% of children)
– Entitlement for children up to age 19 served by:
• Medicaid
• Without health insurance
• American Indians and Alaska Natives
– Underinsured children can receive VFC vaccines at Federally
Qualified Health Centers (FQHCs) or Rural Health Clinics
(RHCs)
• Section 317
– No longer be used to cover routine vaccination of children,
adolescents, and adults who have public or private
insurance that covers vaccination
– Also has objective to improve adult IZ
– Stagnant funding
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Vaccine Financing in the United States
• Medicare
– Covers vaccines for those 65 years and older
– Influenza, Pneumococcal and Hepatitis B –Part B (by legislation)
– All other vaccines –Part D (eg, shingles)
• Medicaid
– Only public sector payer that provides for administration fee
– Admin fee set by states with huge state-to-state variance; states have to
contribute enough funds to draw the maximum federal matching
contribution allowable
– ACA updated the caps are set by CMS for admin fees but states do not
have a floor.
• Private Sector (~50% of children)
– Price of vaccine negotiated with distributors/manufacturers
– Payment negotiated with payers
– Providers responsible for administering vaccine then seeking payment
(compare with pharmaceuticals where patient fills prescription)
The Affordable Care Act
• Assure near-universal, stable, and affordable
coverage by building on the existing system of
public and private health insurance
• Note that intent was to improve access, not
necessarily to improve payment to providers
– While not the primary motivation in ACA, there are
numerous instances where payment is improved
HHS enforces that intent through regulation
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So What Does the ACA
Mean for
Immunizations?
Private Insurance and Group Health
Plans
• ACA mandates provision of ACIP-recommended
vaccines at no cost-sharing
– Must cover adult children up to age 26 years
– No pre-existing conditions for children <18 years
• No plan is required to cover vaccinations
delivered by an out-of-network provider.
– Plans that do cover out-of-network provider can do
so at out-of-network cost-sharing standards
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Self-Insured Group Health Benefit Plans
(ERISA plans)
The ACA extended many of its standards to the
self-insured ERISA group health plans
• In particular, all ERISA plans are subject to the ACA’s
standards on preventive services coverage
• Thus, must cover all ACIP-recommended vaccines at no
cost-sharing
What are Grandfathered Plans?
State-regulated private health insurance sold
in individual and group health markets, prior
to March 23, 2010, are grandfathered into the
ACA
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Loss of grandfathered status
Grandfathered status is lost if:*
• Plans reduce or eliminate existing coverage
• Plans increase deductibles or co-payments by more than
rate of medical inflation plus 15%
• Plans require patients to switch to another grandfathered
plan with fewer benefits or higher cost-sharing to avoid
new patient protections implemented by ACA
• Plans are acquired by or merge with another plan to avoid
complying with ACA
* From: http://www.healthreform.gov/newsroom/keeping_the_health_plan_you_have.html.
Change in Number of Grandfathered Plans**
*p<.05; statistically different from previous year
**Kaiser Family Foundation and Health Research and Educational Trust, 2014. Employer Health
Benefits 2014 Annual Survey. At: http://kff.org/report-section/ehbs-2013-section-13/.
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State regulated health insurance
ACA established market standards for state-
regulated health insurance (eg, coops, FEHBP)
regardless whether through an exchange or in open
market
• Essential health benefits, including preventive services,
must be covered
• State health insurance exchanges must be established by
2014 for small businesses
All state-regulated, non-grandfathered insurance
plans must include ACIP-recommended vaccines at
no cost-sharing
Medicaid Expansion
Effective 2014, all non-elderly persons with incomes up to
133% FPL, based on “modified adjusted gross income,” are
Medicaid eligible, in states that opt in*
• States offer new eligible enrollees an “alternative
benefits package,” which includes immunization
services to children and adults at no cost sharing**
• States decide whether existing Medicaid enrollees are to
be covered for the alternative benefits package
• Creates disparity between newly eligible and already
enrolled persons in expanded states, and between
expanded states and states with traditional Medicaid
*National Federation of Independent Business v. Sebelius. Roberts, C.J., Slip Opin. at 50. Available at:
http://www.kff.org/healthreform/upload/8332.pdf
**CMS Final regulation, July 5 2013. Available at:
http://www.ofr.gov/%28X%281%29S%281vpecb3pcilomwwvusd4jf2b%29%29/OFRUpload/OFRData/2013-16271_PI.pdf.
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Where states are on expanded Medicaid
28 states +
DC
expanding
Medicaid
Medicaid& ACA: Standardizing Immunization Coverage*
InStatesImplementing/Reviewing Expansion (n=32)
9 states did not respond to GW survey: IL, KS, NH, NC, OH, PA, RI, WV, WI = Standardizing IZ Coverage Unknown
NO DECISION TO STANDARDIZE
WILL
WILLNOT STANDARDIZE COVERAGE (n=20) COVERAGE (n=5)
STANDARDIZE
18states = ACIP Coverage in 2012 2 states = ACIP Coverage in 2012
COVERAGE
2 STATES= DO NOT COVER TO ACIP in 2012 3 STATES = DO NOT COVER TO
(n=1)
ACIP in 2012
Arkansas California Minnesota DC Indiana ARIZONA
Connecticut Missouri N. DAKOTA Kentucky COLORADO
Delaware Nevada WASHINGTON
Hawaii New Jersey
In 2012,did not Iowa N. Mexico These states
cover : Maryland N. York will manage
• Varicella Mass. Oregon 2 different
• HPV Michigan Utah benefit
• Zoster Vermont packages
Virginia
*Source: Milken Institute/SPH Medicaid Benefit Design and Cost-sharing Policy 2013 –Presented by Alexandra 18
Stewart at 2014 NAIIS Meeting, Atlanta, GA
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1% FMAP (Section 4106 of ACA) - Update
• To incentivize states to cover preventive services, ACA
provides for a 1 percent increase in state’s FMAP for
preventive services if they cover all USPSTF Grade A/B
recommended preventive services and all ACIP-
recommended vaccines without cost sharing.
• CMS has provided guidance on this provision
– States will have to submit a state plan amendment in order to
receive this benefit
– 11 states have approved 4106 SPAs:
• CA, CO, DE, HI, KY, NV, NH, NJ, NY, OH, WI
– There is no deadline for states to submit SPAs and no end
date for the 1 percent increase
Medicaid Primary Care Payment Increase
• Medicaid “Bump Up” - payment increase for primary
care services to 100% of Medicare payment rates;
100% FMAP for first 2 years*
– Increases immunization administration fee to Medicare
levels for two years: 2013 and 2014
– Intent was to encourage physician participation as Medicaid
expanded.
– Opportunity to show importance of adequate payment on
coverage
*Section 1202 of the Affordable Care Act (ACA)
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